Photodynamic Therapy for Age-Related Macular Degeneration in Japanese Patients: Results After One Year

Polypoidal choroidal vasculopathy: Pearls in diagnosis and management

Polypoidal choroidal vasculopathy (PCV) is increasingly recognized as an important cause of exudative maculopathy in Asians as against Wet age-related macular degeneration in Caucasians. A panel of retinal experts methodically evaluated pertinent updated literature on PCV with thorough PubMed/MEDLINE search. Based on this, the panel agreed upon and proposed the current consensus recommendations in the diagnosis (clinical and imaging), management and follow-up schedule of PCV. Diagnosis of PCV should be based on the gold standard indocyanine green angiography which demonstrates early nodular hyperfluorescence signifying the polyp with additional features such as abnormal vascular network (AVN). Optical coherence tomography is an excellent adjuvant for diagnosing PCV, monitoring disease activity, and decision-making regarding the treatment. Current treatment modalities for PCV include photodynamic therapy, anti-vascular endothelial growth factor agents, and thermal laser. Choice of specific treatment modality and prognosis depends on multiple factors such as the location and size of PCV lesion, presence or absence of polyp with residual AVN, amount of submacular hemorrhage, presence or absence of leakage on fundus fluorescein angiography, visual acuity, and so on. Current recommendations would be invaluable for the treating physician in diagnosing PCV and in formulating the best possible individualized treatment strategy for optimal outcomes in PCV management.

Intravitreal aflibercept for exudative age-related macular degeneration with good visual acuity: 2-year results of a prospective study

Purpose

We report the 2-year outcomes of intravitreal aflibercept (IVA) for exudative age-related macular degeneration (AMD) with good visual acuity (VA) and examine the baseline factors associated with good visual outcome.

Materials and methods

This multicenter, prospective study evaluated 39 eyes (39 AMD patients) enrolled from August 2013 to August 2014 at 12 and 24 months. Only patients with initial best-corrected VA (BCVA) >0.3 logarithm of the minimum angle of resolution (20/40 Snellen) were eligible. Three consecutive monthly IVA injections were followed by 2 monthly injections for 12 months. Thereafter, patients received injections on a treat- and-extend regimen for up to 24 months. Outcome measures included BCVA and central macular thickness (CMT) at 12 and 24 months. Post hoc analysis, BCVA, and CMT were evaluated by AMD types (typical AMD [tAMD], type 1, and type 2 polypoidal choroidal vasculopathy [PCV]). Baseline characteristics and BCVA associations were evaluated with linear regression analysis and Student’s t-test.

Results

Mean age was 69 years and 26 of 39 eyes were male. tAMD, type 1 and type 2 PCV occurred in 18, 12, and 9 eyes, respectively. Baseline mean BCVA was 0.097 logarithm of the minimum angle of resolution (20/25 Snellen) and showed significant improvement to 0.058 (20/22 Snellen, P=0.03) at 12 months and 0.066 (20/23) at 24 months. CMT improved significantly from 320 (99) µm (mean [SD]) to 250 (93) µm (P=0.002) at 12 months and 240 (93) µm (P=0.0005) at 24 months. BCVA and CMT were not significantly different among the three groups. Only subretinal hemorrhage (SRH) was significantly associated with improved BCVA. BCVA change from baseline was −0.12 with SRH and −0.011 without SRH (P=0.017) at 12 months.

Conclusion

IVA showed good efficacy for exudative AMD with good VA at 24 months. tAMD and type 1 and 2 PCV showed similar prognosis. Baseline SRH predicted favorable long-term vision in AMD with good VA.

Polypoidal choroidal vasculopathy: evidence-based guidelines for clinical diagnosis and treatment

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy affecting vision, with clinical features distinct from neovascular age-related macular degeneration. Currently, no evidence-based guidelines exist for its diagnosis and treatment.

METHODS

A panel of experts analyzed a systematic literature search on PCV together with results of the EVEREST trial, the only published randomized controlled clinical trial in PCV. At a subsequent Roundtable meeting, recommendations for the management of PCV were agreed based on this analysis and their own expert opinion.

RESULTS

Diagnosis of PCV should be based on early-phase nodular hyperfluorescence from choroidal vasculature visualized using indocyanine green angiography. Recommended initial treatment of juxtafoveal and subfoveal PCV is either indocyanine green angiography-guided verteporfin photodynamic therapy or verteporfin photodynamic therapy plus 3 × 0.5 mg ranibizumab intravitreal injections 1 month apart. If there is incomplete regression of polyps by indocyanine green angiography, eyes should be retreated with verteporfin photodynamic therapy monotherapy or verteporfin photodynamic therapy plus ranibizumab. If there is complete regression of polyps by indocyanine green angiography, but there is leakage on fluorescein angiography and other clinical or anatomical signs of disease activity, eyes should be retreated with ranibizumab.

CONCLUSION

Practical guidance on the clinical management of PCV is proposed based on expert evaluation of current evidence.

Synthesis andin vitroanticancer activity of water-soluble cationic pyridylporphyrins and their metallocomplexes

Tetrapyrrolic compounds such as porphyrins are known to be prospective chemotherapeutics and photosensitizers for cancer treatment and diagnosis. In this work, water-soluble, meso-substituted cationic pyridyl-porphyrins and their metallocomplexes bearing various central metal atoms ( Ag , Zn , Co , and Fe ) in the porphine ring and various functional groups (allyl, oxyethyl, butyl, and methallyl) at the nitrogen atom in the pyridine ring were synthesized and characterized by1H and13C NMR and UV-visible spectroscopy. Cytotoxic and photodynamic activities of new porphyrins and their metal derivatives were investigated in vitro (KCL-22 cancer cell line of human chronic myeloid leukemia). The cytotoxicity of porphyrins was shown to be dependent on the presence and type of the central metal atom in the porphine ring. Ag -derivatives were more cytotoxic than Co −, Zn −, and Fe − metallocomplexes. The porphyrins bearing allyl-functional groups were evidenced to be more cytotoxic than those which included butyl-, oxyethyl-, and methallyl-groups. The change of nitrogen position in the pyridine ring of Ag -metalloporphyrins from 3(3-N-pyridylporphyrins) to 4(4-N-pyridylporphyrins) induced an increase in the cytotoxic activity of metallocomplexes. All synthesized Ag-metalloporphyrins, except, the oxyethyl-containing one were more cytotoxic than cisplatin. Allyl containing free porphyrin and its Zn -metallocomplex had higher phototoxicity than Ag −, Co −, and Fe -metalloporphyrins. The results obtained can be useful for further investigation of new porphyrins as potential chemotherapeutics and photosensitizers.

Association of lesion size and visual prognosis to polypoidal choroidal vasculopathy

PURPOSE

To investigate the progression of vascular lesions of polypoidal choroidal vasculopathy (PCV) as viewed with indocyanine green angiography and the visual prognosis of these eyes.

DESIGN

Retrospective case study.

METHODS

We reviewed retrospectively the medical records of 88 consecutive patients (88 eyes) with PCV who had been examined with indocyanine green angiography for more than 2 years.

RESULTS

Depending on the initial area of the vascular lesion, eyes were divided into smaller PCV (baseline area of lesion being < 1 disc area [DA], n = 22) and larger PCV (baseline area of lesion being ≥ 1 DA, n = 66). In larger PCV, the mean area of the lesion progressed significantly from 6.49 ± 8.96 mm(2) to 16.27 ± 14.19 mm(2) (P < .0001) with marked deterioration of visual acuity (P < .0001) during follow-up. In contrast, smaller PCV often showed minimal progression of the lesion, only limited exudative change, and the eyes maintained their initially good vision to the final visit. Smaller PCV lesions rarely progressed to extensive PCV lesions. Severe vision-threatening complications (ie, suprachoroidal hemorrhage, vitreous hemorrhage, and tears of the retinal pigment epithelium) were seen only in eyes with larger PCV, and in studying single nucleotide polymorphisms A69S of ARMS2 genes, there was a significant difference in T allele frequency between individuals with smaller PCV and those with larger PCV (20.2% vs 79.8%; P = .0235).

CONCLUSIONS

PCV with small vascular lesions shows minimal progression and no vision-threatening complications, and these eyes often maintain good visual acuity for a long time.

Association of LOC387715 A69S genotype with visual prognosis after photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate whether there is an association of the LOC387715 A69S genotype with visual prognosis after photodynamic therapy in eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

Photodynamic therapy was repeated every 3 months until the disappearance of angiographic signs of active lesions in 71 eyes of 71 patients with PCV who were followed-up for at least 12 months. All patients were genotyped for LOC387715 A69S polymorphism (rs10490924, risk-allele T).

RESULTS

Although there was no statistically significant difference in the mean baseline visual acuity (P = 0.53) among the 3 genotypes, there was a statistically significant difference in the visual acuity both at the 12-month and final visits (P = 0.002 and P < 0.001, respectively) with the poorer acuity in patients with the higher "T-"allele frequency. "T" allele was more frequently observed in those with the recurred PCV lesions (odds ratio: 5.8, 95% confidential interval: 2.3-15.1, T vs. G).

CONCLUSION

There is a pharmacogenetic association between the LOC387715 A69S variant and the long-term results after photodynamic therapy in eyes with PCV. The LOC387715 A69S genotype is of clinical importance to predict the visual prognosis after photodynamic therapy in eyes with PCV. These results should be confirmed or refuted by replication studies.

Three-year follow-up results of photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To evaluate the visual outcomes and changes in abnormal vascular networks and polypoidal lesions of polypoidal choroidal vasculopathy (PCV) 3 years after photodynamic therapy (PDT).

METHODS

We studied 43 eyes of 43 patients with PCV for 3 years. Fundus appearance, fluorescein angiography (FA) and indocyanine green angiography (IA) findings, and visual acuity (VA) before the initial PDT were compared with those 3 months, 1 year, 2 years, and 3 years after treatment.

RESULTS

In 24 of the 43 eyes, enlargement of the abnormal vascular network continued in a manner similar to that before PDT on IA; in eight eyes, transformation into polypoidal choroidal neovascularization (CNV) with enlargement was detected; and two eyes had the appearance of classic CNV on FA. Polypoidal lesions recurred at 3 years in 33 of the 43 eyes (77%). Mean VA (logarithm of the minimum angle of resolution) of all 43 eyes decreased to below baseline at 3 years after the initial PDT. This decrease can be explained by foveal atrophy after absorption of recurrent hemorrhagic or exudative detachment.

CONCLUSION

Long-term visual outcomes were not good owing to the high frequency of recurrent polypoidal lesions, as well as enlargement and neovascular changes involving abnormal vascular networks.

Polypoidal choroidal vasculopathy: a review

More than a quarter century has passed since the original description of polypoidal choroidal vasculopathy (PCV) in 1982 as a peculiar hemorrhagic disorder involving the macula characterized by recurrent subretinal pigment epithelial bleeding. In the ensuing years, numerous reports have described the expanded clinical spectrum of this entity. PCV is the principal vascular composition of patients of pigmented races experiencing neovascular maculopathies, particularly African Americans and Asians. This form of neovascularization is now known to occur in white patients with or without concomitant drusen, and the site of involvement has extended from the peripapillary area to the peripheral fundus. Indocyanine green angiography has made detection of these abnormal vascular changes more reliable and definitive. More precise diagnosis has also led to a better understanding of specific clinical features that distinguish PCV from more typical proliferations of abnormal choroidal vessels. We review the nature of PCV, including its genetic basis, demographic features, histopathology, clinical manifestations, natural course, response to treatments, and the histopathological and genetic bases. We emphasize multimodal ophthalmic imaging of these vessels, in particular fluorescein and indocyanine green angiography and optical coherence tomography.

Verteporfin PDT for non-standard indications--a review of current literature

BACKGROUND

Verteporfin photodynamic therapy (PDT) is approved for the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD), as well as for subfoveal CNV due to pathologic myopia and ocular histoplasmosis syndrome. Verteporfin PDT addresses the underlying pathology of ocular vascular disorders through its angio-occlusive mechanism of action, which reduces both visual acuity loss and the underlying leakage associated with lesions. Verteporfin PDT has also been associated with encouraging treatment outcomes in case studies involving patients with choroidal vascular disorders such as polypoidal choroidal vasculopathy, central serous chorioretinopathy, choroidal haemangioma, angioid streaks, and inflammatory CNV, i.e. conditions currently considered as non-standard indications of verteporfin PDT. In many studies, outcomes were better than expected based on the natural courses of each of these conditions. Although the anti-vascular endothelial growth factor (VEGF) therapies, ranibizumab and pegaptanib, have been approved for CNV due to AMD, their role in these other choroidal vascular disorders remains to be established. We summarize current literature that has documented the use of verteporfin PDT in these conditions.

CONCLUSIONS

The complex pathogenesis of CNV provides a rationale for investigating combination approaches comprising verteporfin PDT and anti-VEGF therapies. Randomized controlled studies are warranted to confirm the preliminary results of verteporfin PDT as a monotherapy or in combination with anti-VEGF therapies in the treatment of a variety of choroidal vascular conditions.

Association between foveal photoreceptor integrity and visual outcome in neovascular age-related macular degeneration

PURPOSE

To evaluate the correlation between visual outcome and foveal photoreceptor integrity after successful treatment of eyes with neovascular age-related macular degeneration (AMD).

DESIGN

Retrospective chart review.

METHODS

We retrospectively studied the medical records of 51 eyes of 51 patients with neovascular AMD who were treated successfully with photodynamic therapy (PDT). All eyes were followed-up for more than 24 months after the initial treatment. Using spectral-domain optical coherence tomography, the status of the inner segment and outer segment (IS/OS) photoreceptor junction was assessed as a hallmark of the integrity of the foveal photoreceptor layer.

RESULTS

At the final visit, no eyes showed an exudative change. A complete or discontinuous IS/OS line was detected beneath the fovea in 8 (15.7%) and 25 (29.4%) eyes, respectively, whereas 28 (54.9%) had no IS/OS line. Eyes with a continuous or discontinuous IS/OS line beneath the fovea had better final visual acuity (VA) than did eyes without an IS/OS line (P < .001, respectively). Of the 51 eyes, 36 showed polypoidal choroidal vasculopathy (PCV), whereas 15 were diagnosed as having typical AMD without PCV. Visual outcome was significantly better in eyes with PCV (P = .026). Most eyes (13/15; 86.7%) with typical AMD had no IS/OS line at the final visit, whereas only 13 (36.1%) of the 36 eyes with PCV had no IS/OS line beneath the fovea.

CONCLUSIONS

Integrity of the photoreceptor layer beneath the fovea is associated with the final VA in neovascular AMD after successful PDT.

Recurrence of polypoidal choroidal vasculopathy after photodynamic therapy

PURPOSE

To evaluate the recurrence of polypoidal lesions after photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective review of data on 28 patients with PCV treated with PDT. The recurrent polypoidal lesions were observed with fluorescein and indocyanine green angiography.

RESULTS

In 26 of the 28 eyes the PCV remained inactive for more than 12 months after one to three treatments with PDT. Recurrence of the polypoidal lesions after more than a 12-month inactive period was reported in eight eyes: three at 15 months, two at 18 months, and three at 21 months. Kaplan-Meier estimates of recurrence were 11.5% at 15 months, 20.4% at 18 months, and 38.8% at 21 months, with no subsequent recurrence until passage of 36 months of inactivity after the last PDT. Additional PDT after recurrence improved or preserved visual acuity in 80% of those treated compared to the visual acuity before the first PDT.

CONCLUSIONS

Recurrence of PCV occurs in about 40% of eyes treated for PCV even after a long period of inactivity, so careful follow-up is needed.